Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. At some point in our lives, the majority of us will experience acne. The breakouts on our face and other parts of our body that can impact our confidence and self-esteem.

Acne affects up to 50 million Americans every year, and 85 percent of people between the ages of 12 and 24 experience at least minor acne. While so many of us experience these breakouts, they’re often confusing and conflicting pieces of advice and myths that may make it more difficult for us to tackle these acne breakouts in the most effective way.

The good news is that for whatever type and severity of acne, there are treatments that can help us to clear our skin. Let me introduce my guest, Randal Antle.

Randal is a certified physician assistant and has been a dermatology PA in Atlanta for the past 15 years. Randal practices medical and cosmetic dermatology and has a special interest in the treatment of acne in all age groups, from pediatrics through adulthood.

She's a member of the American Academy of Physicians Assistants, The Georgia Dermatology Physician Assistants, and the Society of Dermatology Physician Assistants. Welcome to the WebMD Health Discovered podcast, Randal. 

Randal P. Antle MMSc, PA-C: Thank you so much. I'm really happy to be here and really honored to be on your program. 

Pathak: So, before we dig into our topic today, I'd love to ask about your own personal health discovery. What was that aha moment around your practice of dermatology and specifically your interest in helping people manage acne?

Antle: So, you know, in dermatology, it's such an interesting specialty. It's kind of unique when we do clinical rotations and training, we kind of travel through lots of different specialties, primary care, things like that. Specific to dermatology, what drew me to it is it's so visual, you can just really diagnose things by looking sometimes and even tracking progress as a provider, patients can see progress on their skin.

We're not relying as much on tests like laboratory values or imaging. It's just something we can see with our eyes. And that is something that really draws me to it. I think specifically to acne, kind of an an aha moment in my practice is there's such a psychosocial aspect to acne. I think all of us have maybe had some breakouts here or there, we don't want to leave the house and that side of it can be so undervalued.

And being a part of treating acne, improving a patient's acne is just so rewarding. That aha moment happens when you see someone come back in for follow up. Their acne is hopefully clear, and their smile is bigger. They walk in with different body language; they just feel better about themselves. And that is so fulfilling as a provider to be a part of that.

Pathak: Can you help us understand acne and the different types of acne?

Antle: So acne in kind of a nutshell is a process where within the skin we have hair follicles and those are very prominently on the face or sometimes the trunk as well. And an acne process is where those hair follicles become more clogged with oil. Sometimes we call that sebum, and then there can be some dead skin cells that contribute to that.

That can be those classic clogged pores or comedones we see. And then some people with their skin, that will lead to an increase in acne bacteria. It varies, but that can trigger, additionally, an inflammatory process where we get those true pimples or inflammatory spots that look like cysts. They're tender, occasionally those rupture and just has that downstream effect of things that we see relating to acne on the skin.

Pathak How do blackheads, whiteheads fit into when we're thinking about acne?

Antle: That goes into that clogged pore picture in an open comedone when that sebum is exposed to oxygen, it has a darker color. So we call that kind of a blackhead when the clogged pore is maybe a little bit more closed with a layer of skin over top and the body is trying to push it out.

We see those dead skin cells cause more of a pustule or what you might think of as a whitehead. 

Pathak: Help us understand timing of these acne outbreaks. So, in general, most of us recognize that it's one of the first signs of puberty in our children. What hormonal shifts are happening to cause these outbreaks specifically during adolescence or puberty.

Antle: So, during puberty we're going to see those sex hormones increase, specifically androgen-like testosterone or DHEAs is another one. And when those hormones increase, it often has a downstream effect of increasing that oil production. And when we have that oil production increase, then all of those things follow along afterwards with pimples, the breakouts, and things like that.

So often there's not a problem with the hormones. It's not that they're abnormal. It's just that there's been a shift or increase in the levels.

Pathak: What are some of the really common myths or misconceptions that often sort of myth busting in the office when it comes to teen acne? 

Antle: Oh my goodness, there are so many. Where do I start? I think one of the most common things I hear all the time is that patients might believe it's related to water intake. A lot of people say, “Oh, I just haven't been drinking enough water.” And, sure, it's great to stay hydrated, but I'm not sure that really has a true effect on acne that I can correlate with.

So, that's just kind of something that is out there in the world. I'm not sure why. I think people sometimes associate acne as maybe their skin is dirty, that it has an issue with personal hygiene, that is somewhat of a myth. Of course we want to clean the skin, but often people will have acne with very impeccable hygiene habits.

And then, the last thing I'll say is, a lot of people will feel that they might be causing their acne. Maybe they are using the wrong product or they're doing something to trigger their acne. And a lot of my counseling with patients is sometimes just removing that feeling of them feeling like it's their fault and something that they are directly causing.

Pathak: In terms of things that we might be eating, are there any connections there? 

Antle: There's definitely been a big, debunked myth about chocolate and acne. A lot of studies really have disproven that there is a connection there, but I will say we have some evidence pointing towards high glycemic foods maybe worsening acne or correlating with more acne outbreaks.

So, things we think of are very processed foods or especially sugary beverages, I think do play a little bit of a role in sometimes worsening it, but it doesn't mean if we remove that completely from our diet, the acne would go completely away. So, it's important to know that might not be part of it but could be just exacerbating it.

Milk has been somewhat of a theory, different studies kind of point towards different things, but I will say just anecdotally, drinking milk or sometimes dairy products, I do hear from patients, certain patients will say, “this really makes my acne worse, you know, I see a big difference if I consume dairy versus not.”

And we're kind of cautious to blanketly tell everybody to avoid milk or dairy, sometimes that can be an important component of diet. But I do think dairy can sometimes increase the inflammatory response in certain individuals, not everybody. So, that's something else that we do mention sometimes.

Pathak: That's really helpful. So, help us kind of think through, you mentioned that sometimes people are concerned that their own sort of personal hygiene habits might add to it. What do you recommend in terms of an optimal regimen for self-care for your skin?

Antle: Our foundation of a lot of our acne plans are going to be just kind of a morning nighttime routine and a lot of times I keep it as simplified as possible, but one of the first things we'll do is encourage people to try a neutral or balanced cleanser, something not too strong. A lot of times with acne, people are grabbing everything they can to peel and strip and exfoliate, and I’m often going to point towards just something more balanced, not too harsh.

An oil free moisturizer, believe it or not, sometimes actually using a moisturizer can help some of that inflammatory issue we see in the skin as well. So that's often a good first step.

Pathak: And so that's both for morning and for evening?

Antle: Correct. Yeah. We want to try to get in that habit. 

Pathak: In terms of, right now so it's summer, if you have a lot of active acne, how do you counsel around sunscreen?

Antle: Generally, things that we're going to apply for the face with an acne picture, we want to look for things that have a label saying non pore clogging, oil free, or sometimes it will say non comedogenic. And those products are generally going to be ingredients that won't contribute to acne. Some of our acne ingredients, specifically the family of medicines called retinols or retinoids, those can turn the skin over a little bit faster.

They help by reducing oil but almost have an exfoliating effect. And so those medicines specifically can increase our sun sensitivity. So, when we're using them, especially during the summer months, we want to balance that with sun protection during the day. 

Pathak: What about some of the over-the-counter acne specific treatments? Do you recommend those, or do you sort of find preferentially that you're better off to get a prescription medication? 

Antle: There's a lot now over the counter. I will say and especially with social media, I call it TikTok dermatology, people have a lot of access to what is available. And that is sometimes a good thing, sometimes confusing, but I definitely think it's worth starting with some over-the-counter products.

There are two really great ingredients to think about adding into that morning, night cleansing routine, that I mentioned, one ingredient that we can see kind of in that family of the retinoid types of topical creams, is available now. It went over the counter in 2016, it's called adapalene gel 0.1%. 

It should be used with caution. It can cause dryness or irritation if you do too much of it. Also has that concern of the sun sensitivity, but that's something that some people will just get started with and see if that helps reduce that oil and see that benefit. Also, another ingredient that we’ll throw into the mix is called benzoyl peroxide.

Really widely available for many, many years. It can help reduce some inflammation. We can also see it reduce acne bacteria in the skin. One caution there is, is it does bleach fabric. So, sometimes I choose that product as a cleanser formula. It is available occasionally as a spot treat or a topical gel.

You would apply all over, but you do have to be careful that it doesn't ruin your towels and pillowcases.

Pathak: I have just a general question around different phenotypes of acne breakouts, right? Some of us we know that we may have had more significant breakouts. Some of us might have just a pimple here and there. So, if you've made it through puberty and you've never had a significant outbreak, does that mean that you're past the most significant phase of acne in your life? Or could you still have more severe acne later on?

Antle: I definitely see acne occur in all age groups and treating acne over many years, some of our patients are teenagers, but really a vast majority are actually adults. Many adults will come in and say, “I've never had acne before. I've never had skin problems before.” That kind of goes into more of that hormonal aspect of acne. Especially for women, when we see hormonal shifts that occur sometimes as we might be pregnant or postpartum, or maybe perimenopausal or menopausal.

Those shifts that occur we can see trigger acne and sometimes it can be quite severe actually, even when somebody has never experienced acne before. I wouldn't say you're always out of the clear if you never had it as a teenager. Sometimes that applies more to our male patients. They don't tend to have as many of those hormone shifts.

There is also that cousin to acne that we call rosacea. That’s more of an inflammatory type of acne, less driven by oil production, more so with flushing and blushing and things that cause redness in the skin. And that is something we tend to see a little bit in our later years.

Some people can even have a crossover where they have an acne side to their breakouts and also a rosacea side to what we're seeing.

Pathak: So, how do you treat or manage patients differently based on their age? 

Antle: So, age is a factor when we're dealing with somebody in more of an adolescent age group. I personally tend to go a little bit more slowly. We don't want to overload someone with a lot of oral medicines right out of the gate. Sometimes, surprisingly, those patients actually do really well with just some basic topicals, even when I might not think they would.

So, I do tend to approach my pediatric patients with just a little more caution. And I think that just comes from being a parent, a mother, I don't want to overload kids with medicine right out of the gate. As far as adults go, sometimes we do have a few more options, specifically for women.

We use a medication that's called spironolactone. This is a potassium sparing diuretic. We don't use this in men. It can cause some issues with men, but for women, especially our adult patients getting into our thirties, forties, fifties, that can be a great medicine. And I really don't use that in our adolescent female patients. 

Pathak: And then what about certain medicines and concerns around pregnancy or potential pregnancy? How do you think about that or counsel patients around certain medicines that you wouldn't necessarily want them to be on during pregnancy or if they're anticipating or thinking about it?

Antle: So, the retinol products, retinoids, tretinoin, things like that, can cause birth defects during pregnancy. We really try to avoid those if someone is actively attempting pregnancy or obviously currently pregnant. Oral medications, most of them we don't use during pregnancy. We often use oral antibiotics to treat acne sometimes in lower doses, things in the tetracycline family are used commonly. Doxycycline, minocycline, and those really shouldn't be used during pregnancy.

Additionally, there's the commonly known medicine called isotretinoin. That's one of our most effective acne treatments, but can really have a high risk of causing birth defects. So, when we have patients on that medicine who can bear children, we actually monitor pregnancy testing monthly in order to be able to prescribe that medication.

Pathak: I'm really curious about when you step up treatment from topical to oral based on the amount of acne. Are there certain signs that you're seeing in the acne, the location of the acne that make you think, OK, I'm going to just start off slowly versus this is someone I'm going to start off with an oral regimen as well as the topical. 

Antle: Absolutely. If a patient has acne in multiple body areas: face, back, shoulders, chest, it's a challenge to get topical medicines on all of those areas with enough consistency, and so I will definitely move forward with oral medicine earlier in situations like that. One of our big priorities is we want to prevent scarring with acne.

So, especially in skin of color, we can see significant hyper pigmentation. When we have a lot of inflamed areas, we can cause hypertrophic scarring. That's kind of like a raised textured scarring. Sometimes also we see these ice pick scars where the skin will have some divots, not that smooth texture that we often want.

And so if I'm seeing a lot of inflammation, a lot where the skin best way I could describe it is it just looks angry, it's red, it's looks painful, it's irritated. I'm definitely going to be, a little more aggressive, you Obviously, that's joint decision making with the patient or maybe a parent also involved in that there's always risks with every medication that we use.

So, we want to gauge those decisions accordingly. But, as I mentioned earlier, just seeing that confidence boost when we clear acne has such a big impact on relationships, maybe. Getting a job or career path. And so, if I get that sense where this would really help someone, I’m going to not push anything, of course, but really present all those options right out of the gate.

Pathak: And do you find that you have a really high success rate when you find the optimal regimen? 

Antle: Absolutely. I see my patients back pretty closely with acne. I think it's important to know when we start an acne treatment when we see those before and after pictures, that might be on commercials, for example, the typical duration of treatment is about a three month plan to see kind of the before and after.

Some providers see patients closer to that three-month point. I do like to kind of do a check in halfway, maybe six, eight weeks to just see, OK, are we seeing improvement? Is something good happening? And if it's not, I don't want to wait three months, four months, I'm going to move up the ladder in terms of options.

And specifically, that medication called isotretinoin is something that is a great tool for us. It does have some risks. We counsel extensively about those issues before we start, make sure it's safe for that patient, but it can have a long-lasting impact. So, what I mean by that is many patients who do a course of maybe six or seven months of that medication, their acne can go into a remission or we can see a curative benefit.

And it doesn't have to be severe acne. Sometimes it's just really stubborn acne. and I will occasionally start patients on that medicine who dealt with acne for many years, adolescence through early adulthood, and they're just tired of it. They’re wearing lots of makeup to cover it and we will do a course of that isotretinoin and it clears their skin beautifully and sometimes in a long term way, which is very rewarding.

Pathak: So say you've gotten someone to a remission state. Is that going to now be a regimen that they're going to need to be on for a very long period of time indefinitely, or do you find that once you've stabilized it, people can sort of start stepping back their treatment and potentially getting back to just the preventive cleansing regimen?

Antle: I think is very unique to each person, of course, but in most cases That's my hope and when we get to that maybe three four months where skin is doing well, it's very clear I will say to them, let’s scale back. Maybe instead of using your topicals every day, you're putting them on twice a week because it is very cumbersome to do something diligently every day, twice a day, and some people will have very extensive skincare routines and I really try to make it as practical, also affordable. Acne medicines are costly over the counter products are costly.

We spend lots of money with trial and error of things. And so, trying to have that practicality mindset of when can we scale back, but it's not always possible for everybody. It really depends on the situation.

Pathak: So, again, not to bring it back to me, but when I did see you, and I will put myself in that perimenopausal age group, you mentioned certain injectable treatments. Can you talk a little bit about that?

Antle: Yes. And I actually did want to mention that because I think it's so important for people to know that this is an option. with perimenopausal acne or I'd almost say female acne, because we see this a lot with females at different stages of hormonal shifts. We can get these just volcano eruptive cysts that are tender, they're red, they're awful.

And one thing that we offer in our practice, most dermatologists or dermatology providers will do this sometimes estheticians depending on their licensing as well as we do a very small injection of a diluted corticosteroids.

So, what you think of as like a cortisone-type product and we actually just inject it. We use a very small insulin syringe. So, it’s not extremely painful. And when we put the medicine in there, it just calms that right down. Usually, we can see a benefit in 24 to 48 hours. So, if you're in that panic mode of oh my gosh I have an event, if you can get in and, and we can do that, it really is helpful.

Pathak: This has been really so, so helpful. Is there anything that you get asked that I haven't asked you or TikTok dermatology trends that you really want to dispel those myths. I'd love to hear that in our last few minutes together.

Antle: One thing that I will say almost consistently to a lot of people is simpler is sometimes better with acne. In many cases, people are using so many different products, and especially products that might be drying, exfoliating, you know, stripping that skin barrier. And if we just scale that back a little bit, make sure we're using a nice lightweight oil free moisturizer. 

We can decrease that irritation side of things quite a bit. And then we're left with maybe just the acne side of things and less of that, double layer of acne plus irritation. And that is something I really educate people on almost at every visit.

Pathak: I'd love to end with a bite sized action items for anyone who's listening today. What advice would you give to someone who's struggling with acne right now that they could add to their lives that could be something sustainable they could carry forward? 

Antle: That cleansing moisturizing routine I think is really important. I think sunscreen is really important in terms of helping the discoloration. We can see connected with acne, also working in dermatology, we're always promoting sunscreen regardless, but it can help in terms of that scarring aspect or pigmentation change aspect of acne. 

But starting with that simple skin care routine, maybe adding one or two acne ingredients over the counter, some of the ones that I may have mentioned. And then if you're not seeing a difference, maybe after two months or so, seek out care. Many people wait very long, they go months and months and months and not everybody has access to a dermatologist, a specialist, but sometimes primary care doctors will actually prescribe.

I know a lot of our pediatricians will prescribe something to get started with maybe while you're waiting to get access to a dermatologist. So, always important to get going, get started. But definitely go up to that next level of getting a specialist to help you out if you're not seeing enough improvement.

Pathak: Thank you so, so much for being with us today, Randal. I really appreciate your time.

Antle: Thank you so much for having me. I so enjoyed talking about this with you.

Pathak: We've talked with Randal Antle about all things acne across the lifespan from pediatrics to perimenopausal and beyond. I know what I'm taking away from it. This conversation is that sometimes when you do have a breakout or a longer lasting breakout, it's always beneficial to try these regimens that you've talked about and then seek out more expert advice if what you're doing isn't working. 

To find more information about Randal Antle, visit DermGA.com and we'll have that information in our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you're interested in or questions for future guests, please send me a note at webmdpodcastatwebmd.net. This is Dr Neha Pathak for the WebMD Health Discovered podcast.